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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601324
Report Date: 01/12/2023
Date Signed: 01/12/2023 12:57:35 PM

Document Has Been Signed on 01/12/2023 12:57 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ELWYN NC - VISTAFACILITY NUMBER:
198601324
ADMINISTRATOR:HAZEL ANGELI GATANFACILITY TYPE:
734
ADDRESS:6034 N VISTA STTELEPHONE:
(626) 451-0550
CITY:SAN GABRIELSTATE: CAZIP CODE:
91775
CAPACITY: 4CENSUS: 3DATE:
01/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Sally Wu, RNTIME COMPLETED:
01:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit focusing on Infection Control Practices. LPA met with RN Sally Wu and explained the purpose of the visit telephonically to Administrator Hazel Gatan. This facility is licensed as an Adult Residential Facility for Persons with Special Healthcare Needs (ARFPSHN) vendored by San Gabriel/Pomona Regional Center. The facility serves four (4) developmentally disabled clients ages 18 and above; of which four (4) may be bedridden. A total of 19 staff members provide care and supervision to the clients. The facility is a single-story home that contains four (4) bedrooms fully equipped with mechanical lifts, two (2) bathrooms of which one (1) is equipped with a mechanical lift, a living room, family room, kitchen, dining room, laundry room, backyard shaded patio area, and attached garage. The last fire drill was conducted on 12/6/2022. Administrator certificate expires 6/9/2024.
OBSERVATIONS:
  • The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Smoke and carbon monoxide detectors are operational. The facility is equipped with a sprinkler system. The facility has three (3) fully charged fire extinguishers.
  • COVID-19 Infection Control Practices and signs that promote hand washing, cough/sneeze etiquette and physical distancing were observed in the entrance, common areas, hallways, bathrooms and client rooms. There is a screening station at the entrance of the facility to screen visitors. Each client room is designated as a COVID-19 isolation room if needed. Facility has an Infection Control & COVID-19 Mitigation Plans.
  • Oxygen tanks were observed to be secured on stands. The back-up power supply is located on the side of the garage. Mechanical lifts in bedrooms and bathrooms are operational.
  • Client files have Individual Health Care Plans (IHCP). 30-day supply of client medications were observed locked and given as prescribed. Two (2) clients have a G-Tube.
  • The kitchen was inspected and has sufficient supply of 2 day perishable & 7 day non-perishable food.
  • A posted Emergency Disaster Plan was observed. Facility has an adequate 30-day+ supply of Personal Protective Equipment (PPEs), emergency supplies, and daily consumables supplies. Cleaning supplies and toxic substances are locked/ inaccessible to clients.
  • Staff files were reviewed for criminal background clearance. Two (2) staff (S1 & S2) do not have criminal record clearance. Corporate staff was advised to contact Caregiver Background Check Bureau regarding pending clearance of S1, and to complete Guardian clearance request for S2.
Per California Code of Regulations, Title 22, a deficiencies and civil penalties were cited.
Exit interview was conducted with RN Sally Wu. A copy of the report and appeal rights were issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 01/12/2023 12:57 PM - It Cannot Be Edited


Created By: Noemi Galarza On 01/12/2023 at 12:35 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ELWYN NC - VISTA
FACILITY NUMBER: 198601324

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(1)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that two (2) staff (S1 & S2) do not have criminal record clearance; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/13/2023
Plan of Correction
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Corporate staff was advised to contact Caregiver Background Check Bureau regarding pending clearance of S1 and to complete Guardian clearance request for S2. Submit proof of correction by tomorrow.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lisa Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 01/12/2023 12:57 PM - It Cannot Be Edited


Created By: Noemi Galarza On 01/12/2023 at 12:35 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ELWYN NC - VISTA
FACILITY NUMBER: 198601324

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that the north side yard passageway had discarded furniture i.e. tables obstructing the passageway; which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/19/2023
Plan of Correction
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Administrator agreed to remove the discarded furniture and submit picture proof of correction.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lisa Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2023


LIC809 (FAS) - (06/04)
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